'Zero harm' NHS plans to be unveiled

Written By Unknown on Selasa, 06 Agustus 2013 | 15.36

5 August 2013 Last updated at 22:05 ET By Nick Triggle Health correspondent, BBC News

Plans to create a culture of "zero harm" in the NHS in England are to be set out later.

The details will be unveiled in a report published by Prof Don Berwick, one of the world's leading experts on patient safety.

He was asked by ministers to look at the systems in place in the NHS after the Stafford Hospital scandal.

Prof Berwick's mantra is that no harm should be the norm in healthcare, much as it is in the airline industry.

His work with other countries has centred on creating a system of openness and honesty and a willingness to learn from mistakes.

'Need a deterrent'

But it is expected that his review will also deal with issues such as the regulation of healthcare assistants and minimum staffing.

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Who is Prof Don Berwick?

Prof Don Berwick has won global recognition for his work on making hospitals safer.

The Institute for Healthcare Improvement, which he co-founded in Cambridge, Massachusetts, has worked with healthcare systems around the world. It is thought that more than a dozen senior leaders from the NHS around the UK have studied there.

Prof Berwick described the NHS as "one of the astounding human endeavours of modern times" in a speech marking its 60th anniversary in 2008.

His admiration for the publicly funded and provided NHS led to criticism from Republicans when President Obama appointed him Administrator of Medicare and Medicaid. He stood down after a year, shortly before facing a nomination hearing.

He was asked to conduct the review after the public inquiry into the neglect and abuse at Stafford Hospital concluded that the NHS had "betrayed" the public by putting corporate self-interest before safety.

Speaking to the BBC in March after his appointment, Prof Berwick, US President Barack Obama's former health adviser, said the "best testimonial to the suffering" of those whose relatives received poor care would be a "healed and better" NHS.

Peter Walsh, chief executive of the campaign group Action Against Medical Accidents, said Prof Berwick's report would be "really important".

He said: "We need to guarantee openness and honesty - and to do that we need a deterrent. Robert Francis [who chaired the Stafford Hospital public inquiry] said there should be a legal duty on individuals. I'm optimistic Don Berwick will come out in favour."

And he added: "There is a need for some form of statutory regulation or register so we can close the gap in the safety net, so they can't just move from one employer to another."

But Katherine Murphy, of the Patients Association, said: "Robert Francis did a very detailed and expensive report with clear recommendations. They need to stop talking about it and just do it.

"It almost looks as though they want to be seen to be doing something rather than just doing it."

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Case study

Chatting at the bedside to a patient - a nurse updates the information in their electronic record via a tablet computer. This is the raw material driving improvements in safety at the Queen Elizabeth II hospital in Birmingham, writes Branwen Jeffreys.

The information from that individual record is translated into day-by-day monitoring of quality. For the nurse in charge of a ward that means they can get information updated at midnight each day on how they are doing on delivering safe care.

It counts infections, patients falling on wards, how many are assessed for the risk of clots and the many thousands of decisions made about medicines.

Mobile computer units on each ward translate that into colour coded charts that give an update at a glance. The data shows what each doctor prescribes, and what drugs each nurse is giving to individual patients.

The aim, says the trust, is to make every error count. Teams are held to account if they're lagging behind and new quality targets are set constantly. But perhaps the most powerful tool is transparency - each ward can see how they're doing compared to the others.

Pre-surgery checklist

The idea of trying to create a zero-harm culture has come out of a global recognition that some patients needlessly suffer or die in hospital because of errors.

It uses experience from industries such as aviation where attempts are made to design systems that reduce the chance of mistakes.

The NHS in England has already drawn extensively on such thinking to reduce errors in operating theatres and levels of hospital-acquired infections such as MRSA.

At its most basic, it can mean the use of checklists before surgery.

Scotland has based its patient safety programme on collaboration with the Massachusetts-based Institute for Health Improvement (IHI), co-founded by Prof Berwick.

It has led to initiatives such as information on the number of falls or infections beingdisplayed on all Scottish hospital wards.


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